Patrick Ambrosetti

long-term Follow-up After First Acute Episode of Sigmoid Diverticulitis: Is Surgery Mandatory? : a Prospective Study of 118 Patients

AbstractPURPOSE: This study was designed to evaluate the long-term natural history of sigmoid diverticulitis in patients treated nonoperatively after a first acute episode and to assess the role of elective colectomy. METHODS: Between 1986 and 1991, 144 patients were admitted for acute diverticulitis diagnosed by abdominal computed tomography and had a successful nonoperative treatment. Remote complications (persisting or recurring diverticulitis) were also diagnosed by computed tomography. Patients had a poor outcome if they had one of these complications. Diverticulitis was graded mild or severe on computed tomography according to Ambrosetti’s criteria. We determined statistically whether young age (≤50 years old) and severe diverticulitis were risk factors for a poor outcome. RESULTS: One hundred eighteen patients with a contributive computed tomographic scan at admission were followed up. Median age was 63 (range, 23–93) years, with a median follow-up of 9.5 (range, 0.2–13.8) years. Eighty patients had no complications, and 38 had remote complications. The incidence of remote complications was the highest (54 percent at 5 years) for young patients with severe diverticulitis on computed tomography and the lowest (19 percent at 5 years) for older patients with mild disease. Young age and severe diverticulitis taken separately were both statistically significant factors of poor outcome (P = 0.007 and P = 0.003, respectively), although age was no longer significant after stratification for disease severity on computed tomography (P = 0.07). Twenty-four patients died. The cause of death was unrelated to diverticulitis in 21 cases and unknown in the remaining 3. CONCLUSIONS: We propose that after a first acute episode of diverticulitis treated nonoperatively, elective colectomy should be offered to young patients (≤50 years old) with severe diverticulitis on computed tomography.

Long-Term Outcome of Mesocolic and Pelvic Diverticular Abscesses of the Left Colon: A Prospective Study of 73 Cases

PURPOSEThe aim of of this study was to evaluate prospectively the long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon.METHODSBetween October 1986 and October 1997, a total of 465 patients urgently admitted to our hospital with a suspected diagnosis of acute left-sided colonic diverticulitis had a CT scan. Of 76 patients (17 percent) who had an associated mesocolic or pelvic abscess, 3 were lost to follow-up. The remaining 73 patients (45 with a mesocolic abscess and 28 with a pelvic abscess) were followed for a median of 43 months.RESULTSof the 45 patients with a mesocolic abscess, 7 (15 percent) required surgery during their first hospitalization versus 11 (39 percent) of the 28 patients with a pelvic abscess (P = 0.04). At the end of follow-up, 22 (58 percent) of the 38 patients with a mesocolic abscess who had successful conservative treatment during their first hospitalization did not need surgical treatment vs. 8 (47 percent) of the 17 who had a pelvic abscess. Altogether, 51 percent of the patients with a mesocolic abscess had surgical treatment versus 71 percent of those with a pelvic abscess (P = 0.09).CONCLUSIONSConsidering the poor outcome of pelvic abscess associated with acute left-sided colonic diverticulitis, percutaneous drainage followed by secondary colectomy seems justified. Mesocolic abscess by itself is not an absolute indication for colectomy.

Acute left colonic diverticulitis—compared performance of computed tomography and water-soluble contrast enema

PURPOSE: The most valuable radiologic examination to be done initially when acute left colonic diverticulitis is suspected is still a matter of controversy. This study compares the performance between water-soluble contrast enema and computed tomography. METHODS: From 1986 to 1997, all patients admitted in our emergency center with clinically suspected left-colonic diverticulitis had a contrast enema and a computed tomography within 72 hours of their admission, unless clinical findings required immediate laparotomy. They were prospectively included in the study if one or both radiologic examinations showed signs of acute diverticulitis or diverticulitis was surgically removed and histologically proven or both. Diverticulitis was considered moderate when computed tomography showed localized thickening of the colonic wall (5 mm or more) and inflammation of pericolic fat and contrast enema showed segmental lumen narrowing and tethered mucosa; it was considered severe when abscess or extraluminal air or contrast or all three were observed on computed tomography and when one or both of the last two signs were seen on contrast enema. Of 542 patients, 420 who had both computed tomography and contrast enema entered the study. RESULTS: The performance of computed tomography was significantly superior to contrast enema in terms of sensitivity (98vs. 92 percent;P=0.01), which was calculated from patients who had their colon removed and whose diverticulitis was histologically proven, and in the evaluation of the severity of the inflammation (26vs. 9 percent;P=0.02). Moreover, of 69 patients who had an associated abscess seen on computed tomography, only 20 (29 percent) had indirect signs of this complication on contrast enema. CONCLUSIONS: In the diagnostic evaluation of acute left-colonic diverticulitis, computed tomography should be preferred to contrast enema as the initial radiologic examination because of its statistically significant superiority in sensitivity and for its significantly better performance in the detection of severe infection, especially when an abscess is associated with the disease.

Sphincter-sparing surgery after preoperative radiotherapy for low rectal cancers: feasibility, oncologic results and quality of life outcomes

The present study assesses the choice of surgical procedure, oncologic results and quality of life (QOL) outcomes in a retrospective cohort of 53 patients with low-lying rectal cancers (within 6 cm of the anal verge) treated surgically following preoperative radiotherapy (RT, median dose 45 Gy) with or without concomitant 5-fluorouracil. QOL was assessed in 23 patients by using two questionnaires developed by the QOL Study Group of the European Organization for Research and Treatment of Cancer: EORTC QLQ-C30 and EORTC QLQ-CR38. After a median interval of 29 days from completion of RT, abdominoperineal resection (APR) was performed in 29 patients (55%), low anterior resection in 23 patients (20 with coloanal anastomosis) and transrectal excision in one patient. The 3-year actuarial overall survival and locoregional control rates were 71.4% and 77.5% respectively, with no differences observed between patients operated by APR or restorative procedures. For all scales of EORTC QLQ-C30 and EORTC QLQ-CR38, no significant differences in median scores were observed between the two surgical groups. Although patients having had APR tended to report a lower body image score (P = 0.12) and more sexual dysfunction in male patients, all APR patients tended to report better physical function, future perspective and global QOL. In conclusion, sphincter-sparing surgery after preoperative RT seems to be feasible, in routine practice, in a significant proportion of low rectal cancers without compromising the oncologic results. However, prospective studies are mandatory to confirm this finding and to clarify the putative QOL advantages of sphincter-conserving approaches.

Incidence, outcome, and proposed management of isolated abscesses complicating acute left-sided colonic diverticulitis

In a prospective evaluation of 140 consecutive patients with acute left-sided colonic diverticulitis demonstrated by computerized tomography (CT) in all cases, 22 (16 percent) were found to have an associated abscess without peritonitis. Thirteen of these 22 required surgery (seven during the first stay and six from 2 to 11 months after the acute episode; median, three months). Nine patients were treated conservatively, eight of whom are now totally asymptomatic 24 months after the initial attack (range, 10–47 months). There were 10 mesocolic abscesses (seven treated with antibiotics alone), nine pelvic abscesses (seven requiring surgery), and three intra-abdominal abscesses, all operated upon. These results suggest that mesocolic abscesses can usually be managed conservatively without drainage; should surgery be necessary,en blocresection with immediate anastomosis can usually be safely performed. Pelvic and intra-abdominal abscesses behave more aggressively and usually require a two-stage surgical procedure when initial percutaneous drainage cannot be performed or is felt to be hazardous.

Acute Diverticulitis of the Left Colon: Value of the Initial CT and Timing of Elective Colectomy

Computed Tomography is undeniably the most useful tool to confirm the suspected diagnosis of acute left-colonic diverticulitis and to objectively grade its severity into moderate diverticulitis (no signs of colonic perforation) and severe diverticulitis (signs of colonic perforation). Indeed, the severity of acute diverticulitis is statistically predictive of the risk both to need surgical treatment of the first episode of acute diverticulitis, and to follow a complicated evolution after successful conservative treatment of the acute phase. Consequently, CT brings a major contribution to define the place of surgery during the acute phase of diverticulitis, and, later on, inside the long-term evolution of the disease after initial successful conservative treatment.

Surgical pitfalls in a patient with type IV Ehlers-Danlos syndrome and spontaneous colonic rupture: Report of a case

PURPOSE: This paper intends to stress the importance of early diagnosis and discuss surgical treatment of Type IV Ehlers-Danlos syndrome (EDS-4), an autosomal dominant connective tissue disease characterized by typical features of the face and extremities, inappropriate and easy bruising, and extreme tissue fragility, which may lead to dramatic and often fatal complications, mostly spontaneous arterial or intestinal rupture. METHODS: We report the case of a 41-year-old female who presented with spontaneous perforation of the sigmoid colon. RESULTS: The patient was seen over a nine-year period, during which time she required six operations and presented with a great number of surgical complications including stenosis of an end-colostomy, repeated subocclusive episodes caused by intraperitoneal adhesions, and enterocutaneous fistulas, finally ending with an ileostomy and short bowel syndrome. It is only after a difficult laparotomy for ovarian cyst excision, marked by numerous adhesions and friable bowel, that the diagnosis of EDS-4 was considered and established. CONCLUSIONS: In case of “idiopathic” spontaneous perforation of the colon in a young adult, features of EDS-4 should be thoroughly looked into and, if found, skin fibroblast culture with collagen Type III analysis performed. The surgical treatment of choice consists of subtotal colectomy and permanent endileostomy. In case of patient refusal, a second-stage ileorectal anastomosis can be performed but carries the high risk of anastomotic leakage.

Assessment of recurrence and complications following uncomplicated diverticulitis

The natural history of sigmoid diverticulitis has been inferred from population‐based or retrospective studies. This study assessed the risk of a recurrent attack following the first episode of uncomplicated diverticulitis.

A clinical and radiological comparison of sigmoid diverticulitis episodes 1 and 2

Aim  After an initial uncomplicated attack, sigmoid diverticulitis may recur, but the morphological characteristics of recurrent diverticulitis have not been investigated. We compared the clinical and radiological severity, the respective location and clinical outcome of the first two episodes of sigmoid diverticulitis.

Critical appraisal of laparoscopic lavage for Hinchey III diverticulitis

Laparoscopic lavage and drainage is a novel approach for managing patients with Hinchey III diverticulitis. However, this less invasive technique has important limitations, which are highlighted in this systematic review. We performed a PubMed search and identified 6 individual series reporting the results of this procedure. An analysis was performed regarding treatment-related morbidity, success rates, and subsequent elective sigmoid resection. Data was available for 287 patients only, of which 213 (74%) were actually presenting with Hinchey III diverticulitis. Reported success rate in this group was 94%, with 3% mortality. Causes of failure were: (1) ongoing sepsis; (2) fecal fistula formation; and (3) perforated sigmoid cancer. Although few patients developed recurrent diverticulitis in follow-up, 106 patients (37%) eventually underwent elective sigmoid resection. Our data indicate that laparoscopic lavage and drainage may benefit a highly selected group of Hinchey III patients. It is unclear whether laparoscopic lavage and drainage should be considered a curative procedure or just a damage control operation. Failure to identify patients with either: (1) feculent peritonitis (Hinchey IV); (2) persistent perforation; or (3) perforated sigmoid cancer, are causes of concern, and will limit the application of this technique.